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X Factor

I was a brand-new intern on the intensive-care unit, and Cassandra was the very first patient I saw there. A petite, slender woman, she was rolled in on a stretcher, accompanied by her tall, athletic husband, Jack.
Cassandra was in her twenties, like me–but mortally ill. That grabbed my attention from the start. But the biggest lesson she taught me came about because we got her prognosis all wrong.
She had lupus, an autoimmune disease that unleashes the raw power of the immune system against the patient’s organs and joints. Fortunately, my attending rheumatologist, Dr. Schmidt, was an expert in lupus and its intricacies. Although small in stature, he cast a large shadow in the field; physicians from near and far referred their most challenging cases for his consultation. He radiated confidence, and, like my teammates, I admired his clinical acumen.

I remember Cassandra’s look of alarm as she told us her story.
“I’ve been feeling awful for days,” she said weakly. “I never felt so tired…I can’t think straight.” When she’d visited Dr. Schmidt, he’d been so concerned about her fatigue and confusion that he had admitted her directly from his clinic.
Like any newly minted intern, I felt a mix of exhilaration and terror as I placed a central venous line so that we could give Cassandra her medicines and transfusions.
As tired and ill as she was, her face also held, I thought, a certain determination. This observation was quickly cut short by my surging anxiety. A lupus patient’s condition can deteriorate rapidly, and I worried that Cassandra’s symptoms might spin out of control.
These fears soon became a reality. Just hours later, as the lupus assaulted Cassandra’s brain, she spiked a high fever and became disoriented. Her breathing grew labored; she was at risk of cardiopulmonary arrest. We started her on broad-spectrum antibiotics, put her on a ventilator to help her breathe, drew blood cultures to rule out sepsis and performed radiologic scans from her head to her pelvis. The tests found nothing. Her kidneys shut down, so we began dialysis. When her blood pressure fell dangerously low, I prescribed medicines to counteract this.
These measures, plus a course of steroids to calm her rampaging immune system, were keeping Cassandra alive; but there was no sign of improvement. She was in dire straits. Dr. Schmidt told me that death was imminent.
“I’ve never seen anyone like her leave the hospital alive,” he said brusquely.
Because her decline had been so swift and inexplicable, he decided to ask Jack for permission to conduct an autopsy. (When death looms so unexpectedly, doctors often ask the family’s permission before the fact, for fear that their grief afterwards may make them incapable of giving consent.)
Years have passed since I watched Dr. Schmidt talk with Jack, but the memory is still fresh. It was painfully difficult to witness.
“We have no hope left for Cassandra,” Dr. Schmidt said gently, his face and voice leaving no room for doubt.
Hearing this, Jack seemed to shrink into himself. He asked only one question: “Could you be wrong?”
“No,” Dr. Schmidt said firmly.
Gazing at the floor, Jack seemed resigned. “Please treat her pain,” he said softly. Quietly, he signed his permission for the autopsy.
Awaiting Cassandra’s passing, we did our best to make her comfortable. We didn’t think we’d have long to wait.
But Cassandra had other plans.
A few hours later, to our astonishment, she began to show signs of improvement. By the next morning, her blood pressure and oxygen levels had recovered, her vital signs and laboratory readings were back in the normal range, and her confusion had lifted. As mysteriously as it had declined, her condition had rebounded.
Stunned and euphoric, we headed to Cassandra’s bed to take her off of the ventilator and dialysis machines. When we arrived, Jack was there at her bedside.
“I have incredible news,” I told him, barely able to hide my elation. “Everything has changed, and Cassandra will live.”
In near disbelief, he barely spoke, but watched intently as we disconnected the machines.
I too felt incredulous–I’d never seen anyone dodge death before. But what surprised me even more was Dr. Schmidt’s reaction: He had none. He simply took it all in stride. Perhaps he was embarrassed at being wrong about Cassandra’s prognosis; I never asked. With no sign of happiness or any other emotion, he simply told me to transfer her to a regular medical floor.
Reflecting on Cassandra’s case afterwards, I began to wonder whether there was a deeper truth at play.
Like physics, medicine has an uncertainty principle. It’s impossible to know the inner workings of every cell and organ in a person’s body. And, like physics, medicine uses powerful mathematical tools to deal with uncertainty: Statistics and probability.
Although Dr. Schmidt arguably knew more about lupus than any other doctor alive, Cassandra’s case fell outside even his experience. Her case defied the statistics, so, fairly enough, he concluded that she was on her deathbed.
While medicine, like physics, uses probability to help solve its problems, only medicine includes the human element as a factor in its calculations. Looking back, I wondered if Dr. Schmidt overlooked this vital aspect of Cassandra’s clinical presentation.
I found myself returning to the look of determination I’d glimpsed in her face. In hindsight, this was a clinical sign as real as any of her other symptoms. It indicated her enormous will to live–a force that can overcome seemingly hopeless odds.
To me, Cassandra’s case is a powerful argument that doctors should stay alert to this mysterious but real force in their patients. Otherwise they might give up hope prematurely, as we did.
I regret not asking Cassandra herself why she thought that she’d survived. The chance never arose during her week-long hospitalization, nor when she visited Dr. Schmidt afterwards for checkups. She did tell me that she was back at work, and that her life had returned to normal. And whenever our paths crossed, we’d share a glance, silently acknowledging that we had witnessed something profound.
If I had asked, I feel sure she’d agree that caregivers should be respectful of the human element in medicine. Clearly, it can literally mean the difference between life and death.
My team and I were certain that Cassandra was going to die.
She did not. And therein lies a lesson that I remember to this day.

Ethan Dmitrovsky, an oncologist and physician-scientist, is president of Leidos Biomedical Research and laboratory director of the Frederick National Laboratory for Cancer Research, in Maryland. He previously served as department chair of pharmacology and interim dean at Dartmouth Medical School, as chair of the board of scientific counselors at the National Cancer Institute and as provost at MD Anderson Cancer Center. An avid reader of the history of science and how science serves the public interest, he began writing a dean’s column while at Dartmouth and went on to write essays for the Pittsburgh Post-Gazette, The Detroit News, The ASCO Post, Dartmouth Medicine and elsewhere. “Every scientist is taught how to describe a discovery, but it’s even more rewarding to learn how telling just one patient’s story can transform your outlook on medicine.”


8 thoughts on “X Factor”

  1. Dr. Ethan Dmitrovsky is a honest, generous and success man in his career. Very good story and I’m sure it will encourage a lot of patients with the meanings.

  2. I wonder how come a chance never arose to ask her why she thought she recovered. It’s easy enough to walk the patient out of the office. Sounds like the effort was never made. I wonder also if the author would have found out people were praying for her, and God wasn’t done with her yet here on Earth.

  3. Thank you for sharing this story. Doctors witness so much suffering. And it’s hard to forget those patients who don’t make it out of the hospital. Thus it’s doubly important that we remember those who defy the odds and the caregivers who help that happen. This was such a case, and I found your story a source of much encouragement. I didn’t really like the attitude of the attending, but he was probably typical of the era–and I’m glad that for once he was wrong! When I was 15 years old, my father got sick, avoided seeing the doctor for months, then when he finally did, he was diagnosed with ALL. The doctor told him to “get your affairs in order.” When Dad asked for an estimate of how long he’d live, the doctor said “One month at the most.” Thanks to some new treatments that became available at that time (1970), Dad lived another 21 years. He was never upset about his doctor’s “wrong” prediction–I think he appreciated the frankness and realized he was a lucky man. But in my dad’s case, his doctor was absolutely thrilled to have been wrong, and he praised my father every visit for his strong will to live.

  4. A friend of mine with cancer was told by her doctor, when it returned, that she had less than a year. She was to put her affairs in order. She went to another oncologist. He gave her chemo again, followed by gamma infusions. It’s been 12 years now and he’s discharged her as his patient she’s so healthy. Of course it come back again, but it also couldn’t.

    No doctor, in my opinion, should ever say he’s sure a patient is dying. To express odds is different. To pronounce death ahead of time, no.

  5. Dr. Louis Verardo

    This was a great story about an unexpected happy ending involving a disease which usually is not so forgiving to patients and their doctors. Given the complexity of the human body, I take comfort in knowing that our current understanding of its dysfunction, however detailed, may still have gaps, and those gaps may allow for some prognostic “wiggle room” to offer hope. Perhaps a way to understand the role of the patient’s determination in her positive outcome is to acknowledge the observation, while simultaneously admitting we are not yet able to quantify the biophysical underpinnings of its effect. I’d find that research fascinating, and based on previous work I’ve read, I would imagine an interplay between the immune system and the neuro-endocrine axis.

  6. Stephen C Schoenbaum

    I find this to be a very well written but disturbing story. Dr. Schmidt comes across as an unfeeling, uncaring person. I hope that what is attributed to him here did not characterize many of his interactions with patients; but even then, his actions in this case are inexcusable.

    Although it is stated that it is common to ask for an autopsy in advance of a death, I, and I graduated from medical school over 50 years ago, have never heard of that practice. Even if one thinks it can benefit science, I do not believe it iputs the patient’s or family’s interests first Accordingly, I do not think it is ethically justifiable.

    I’m glad that the author was involved in trying to make Cassandra as comfortable as possible, glad that she rallied, glad that the author was elated, and glad that he has passed on this story.

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